Provider Demographics
NPI:1124399613
Name:CRUZ, CLEOFE SECULAR (RN)
Entity Type:Individual
Prefix:MS
First Name:CLEOFE
Middle Name:SECULAR
Last Name:CRUZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9705 HORACE HARDING EXPY
Mailing Address - Street 2:14-O
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4157
Mailing Address - Country:US
Mailing Address - Phone:347-420-9452
Mailing Address - Fax:
Practice Address - Street 1:1663 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1259
Practice Address - Country:US
Practice Address - Phone:718-998-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY635507163W00000X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY740802257OtherFIDELIS CARE